CALIFORNIA DEPARTMENT OF CORRECTIONS AND …

CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION CALIFORNIA CORRECTIONAL HEALTH CARE SERVICES Health Care Department Operations Manual

3.3.4.2

Licensure and Credentialing

(a) Policy

The California Department of Corrections and Rehabilitation (CDCR), Division of Health Care Services (DHCS) shall

ensure that all dental health care services employees and dental health care contractors whose positions or job

descriptions require licensure, certification and/or credentialing are in compliance with all federal and state licensing

requirements prior to employment.

(b) Purpose

To ensure compliance with all federal and state requirements regarding the licensure, certification and/or credentialing

of dental health care personnel within the CDCR.

(c) Procedure

(1) Each applicant, when being interviewed and prior to being hired, must submit a copy of their relevant Dental license,

Drug Enforcement Administration (DEA) Controlled Substance Registration Certificate (where applicable) and

Basic Life Support (BLS) certification, or a letter of verification from the licensing or certifying agency, to the

hiring authority. Applicants are not eligible for employment without proof of current licensure, certification and/or

credentials.

(2) The hiring authority shall be responsible for requesting verification of licensure, certification and/or credentials

with the appropriate accrediting agency.

(3) Each employee shall thereafter be responsible for keeping their licensure, certification and/or credentials current

and for providing verification of renewal to their supervisor.

(4) Employees who do not maintain current licensure, certification and/or credentials or whose licenses are suspended

or revoked by the Dental Board of California are ineligible for further employment at the time of the expiration,

suspension or revocation of their license, certification and/or credentials.

(5) Verification of current licensure, certification and/or credentials shall be maintained at the facility of assignment by

the local personnel section, and the Health Program Manager III.

(6) ll dental health care staff and contractors shall comply with the Health Care Department Operations Manual

[HCDOM], Section 1.4.5, Health Care Credentialing.

(d) Credentialing

(1) Credentialing of CDCR dentists shall be performed by the Credentialing and Privileging Support Unit of the

California Correctional Health Care Services ? Resource Management and Professional Practice Support Section,

Medical Services Branch. (Reference the HCDOM, Section 1.4.5, Health Care Credentialing).

(2) Credentialing shall be based on:

(A) Documents generated as the result of the peer review process as outlined in the HCDOM, Section

3.3.4.3(c)(3)(F)6. and/or Section (e)(4)(C) of this chapter.

(B) Licensure, certificate, and/or credential verification including any regulatory agency's action(s) against the

clinician's license, credentials and/or DEA Controlled Substance Registration Certificate (where applicable).

(C) Verification that the clinician is not subject to any restriction of privileges at any institution, hospital, or health

care facility.

(D) Verification that the provider has no adverse action(s) from any government funded program including, but not

limited to, suspension from participation or outstanding audits for recovery.

(E) National Practitioner Data Bank information on action(s) taken against the provider.

(3) Under normal circumstances, CDCR dentists shall be credentialed for a period of two years pending review and

approval of their credentialing file. At the end of each two year credentialing cycle, CDCR dentists shall be subject

to the re-credentialing process.

(4) Six months prior to the conclusion of each dentist's two year credentialing cycle they shall be notified that a dentist

shall review their standards of practice and clinical skills.

(e) Clinical Skills

(1) At the time of employment and continuously thereafter, dental practitioners who seek employment with the CDCR,

DHCS, Adult Correctional Dental Care must demonstrate to the Supervising Dentist satisfactory clinical skills as

well as exhibit professional conduct and ethics.

(2) In keeping with the expectations of a dentist licensed by the Dental Board of California, at a minimum all CDCR

dentists shall be expected to possess the ability to:

(A) Clinically supervise dental assistants and dental hygienists.

Chapter 3, Article 3

3.3.4.2, Licensure and Credentialing

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CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION CALIFORNIA CORRECTIONAL HEALTH CARE SERVICES Health Care Department Operations Manual

(B) Perform dental chart reviews. (C) Provide dental consultations and referrals. (D) Follow Dental Board of California, Centers for Disease Control and Prevention, Occupational Safety and Health

Administration and CDCR policies. (E) Perform all aspects of general dentistry including, but not limited to, the diagnosis or treatment, by surgery or

other method, of diseases and lesions of human teeth, alveolar process, gums, jaws, or associated structures. Such diagnosis or treatment may include all necessary related procedures as well as the use of drugs, anesthetic agents, and physical evaluation. (3) Proctoring and Mentoring (Reference the HCDOM, Sections 3.3.4.3(c)(3)(F)2.a. and 3.3.4.3(c)(3)(F)2.b.) (A) The Dental Peer Review Committee (DPRC) shall use the process of proctoring to monitor and review a dentist's skills during their initial probationary period to ensure they can adequately perform the minimum expected clinical skills outlined in Section (e)(2). 1. The DPRC shall take into consideration aspects of a dentist's behavior, professional ethics and clinical

performance that directly impact their ability to successfully perform the minimum expected clinical skills. 2. In addition to monitoring the areas outlined in Section (e)(4)(F), the committee shall look for and identify:

a. Desirable qualities and qualifications for CDCR, DHCS Dental Program employment. b. Demands made or expectations held by a dentist that are beyond the scope of CDCR policies and

mandates. c. Any values or attitudes manifested by a dentist that are in conflict with those of the CDCR and the

DHCS. d. A pattern of resistance to or conflicts with the quality and/or peer review processes. e. Gross mental or physical disabilities that prevent performance of the minimum expected clinical skills. (B) The mentoring process shall be used to foster continuous professional development and training for dentists if they fail to demonstrate acceptable skills. Additional training and mentoring may be required if a dentist fails to demonstrate acceptable skills. (4) Monitoring and Reviewing Clinical Performance (A) The DPRC shall monitor a dentist's standards of practice and clinical skills on an ongoing basis to ensure compliance with accepted standards of care. The monitoring outcomes may be utilized in the formulation of annual performance appraisals and in the proctoring, mentoring and re-credentialing processes. (Reference the HCDOM, Section 3.3.4.3(c)(3)(F)2. and Section (e)(4)(F). (B) DPRC or other dentists performing ongoing monitoring of a dentist's standards of practice and clinical skills shall employ the Dental Peer Review Audit Tool for the monitoring process. (C) Program Support Team (PST) or other dentists reviewing a clinician's standards of practice and clinical skills shall base their decision on institution DPRC records as well as random chart audits. (Reference the HCDOM, Section 3.3.4.3(c)(3)(E)1. (D) In any situation, additional quality or peer review evaluations may be completed as needed. (E) Special cases or critical clinical issues may be referred to the Headquarters Dental Peer Review Committee (HDPRC) for review. (Reference the HCDOM, Section 3.3.4.3(c)(F)7). Personnel issues that do not impact clinical practice shall be referred to the appropriate supervisor. (F) In addition to the items listed in Section (e)(3)(A)2, the DPRC and PST staff shall consider the following when monitoring or reviewing a dentist's standards of practice and clinical skills: 1. Adherence to the HCDOM, Chapter 3, Article 3, Dental Care. 2. Evaluations of standards of practice and clinical skills including, but not limited to: a. Outcomes of procedures performed. b. Utilization management. c. Risk management data. 3. Relevant education, training, or experience acquired subsequent to initial credentialing and appointment or having occurred after the most recent re-credentialing cycle. (G) The DPRC may recommend extension of a dentist's period of proctoring or mentoring or that the dentist's recredentialing cycle be modified.

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CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION CALIFORNIA CORRECTIONAL HEALTH CARE SERVICES Health Care Department Operations Manual

References ? Health Care Department Operations Manual, Chapter 1, Article 4, Section 1.4.5, Health Care Credentialing ? Health Care Department Operations Manual, Chapter 3, Article 3, Dental Care ? Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.4.3, Dental Peer Review

Revision History Effective: 04/2006 Revision: 11/2017, 11/2020, 02/2022

Chapter 3, Article 3

3.3.4.2, Licensure and Credentialing

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